Lw's Physical Assessment

On May 24, 2016, I performed a physical assessment on patient LW who is a 79 year old, Caucasian, female. She came in to the hospital on April 5, 2016 with a diagnosis of hyperkalemia, LW no longer has hyperkalemia instead over the time of her stay at the hospital she developed respiratory failure which is now her diagnosis. During my time with LW, I performed a full body system physical assessment while also obtaining a thorough medical history from the patient, her primary nurse, and her family members. LW is scheduled to be discharged to home on May 25, 2016, with her two sons wh are also her caregivers.

While performing LW’s physical assessment, LW was noted with the following normal and abnormal aging changes. LW is alert and oriented

The reddened areas on LW’s sacrum and mid back, her decreased mobility, urinary incontinence, and difficulty turning herself puts her at a great risk for the development of pressure ulcers over boney areas. The reddened areas can easily become stage II pressure ulcers if the skin isn’t properly cared for. If LW stays in one sport for a long period of time because of decreased mobility and inability to turn and reposition herself without assistance, skin break down occurs because of excessive pressure to one area. A cause of LW’s decreased mobility could be related to her history of osteoporosis. Osteoporosis is known to cause pain during mobility and transfers and bone fractures which can both contribute to decreased mobility. As a result of LW’s decreased mobility and medical history, LW has an increased risk for many complications which includes blood clots. LW’s decreased mobility along with her history of A-fib puts LW at an increased risk for the development of blood clots. In addition to pressure ulcers and blood clots, LW’s decreased mobility and poor fluid intake puts her at a greater risk for constipation. Older adult’s gastric motility decreases with age which puts them at greater risk for constipation. Ambulation and adequate nutrition decreases the risk for constipation. Poor fluid intake doesn’t only put LW at an increased risk for

In order for LW’s risk of pressure ulcer development to be decreased, LW needs to be turned and reposition every 1-2 hours and as needed, which keeps pressure off of the boney areas. Because LW needs assistance with turning and positing, LW and her 2 sons who are also her caregivers will be educated on proper turning and repositioning techniques in which they will have to demonstrate prior to discharge. LW will be kept clean and dry at all times and moisture barrier will be applied. This will be done because increased moisture from urine and feces causes skin breakdown. LW and sons will be educated about the importance of keeping LW clean and dry, verbalizing understanding. LW will be encouraged to ambulate more often, this also relieves pressure from boney prominence increasing blood flow throughout the body. LW and sons will verbalize importance of encouraging LW to ambulate while also demonstrating proper body mechanics when assisting LW with ambulation. LW will be encouraged to spend less time in bed, sitting in recliner or chair occasionally lifting butt from chair/recliner. This also alleviates pressure from sacrum and back. LW and sons will verbalize and demonstrate the importance of lifting butt from chair or recliner when sitting for long periods of